Abortion ‘ six years later
Over a quarter of a million women have accessed safe, legal abortions since the implementation of the Termination of Pregnancy Act in South Africa six years ago. But many are still not aware that services are legal or even exist.
Abortion has been legal in South Africa for more than six years significantly reducing deaths and complications from unsafe abortions.
Since the implementation of the Termination of Pregnancy Act in 1997, 272 602 women have accessed safe, legal terminations of pregnancy (TOP) at public health facilities in South Africa, but many women are still not aware that the service is legal or even exists.
Statistics reveal that 74% of terminations were first trimester TOPs with 52% of women 18 years and older. (The age statistic excludes Gauteng, which accounts for a significant amount of the national service provision).
Experts agree that access continues to be uneven across the nine provinces bearing in mind that regions are resourced unequally. Gauteng province provided 39% of TOPs, followed by the Western Cape’s 13%.
The challenge to decentralise services to a primary health care level remains, as the majority of TOPs are being provided at secondary and tertiary levels while various factors contribute to women presenting for second trimester TOPs.
While the scene has been set for the services required and underwritten by South African law to be provided, the reality of it all is vastly different.
A Case Study
Martha’s * most enduring and traumatic memory of the ordeal was watching her 16-year-old daughter Pamela* suffer for eight hours while her body tried to expel a 12-week-old foetus.
At sunrise Martha* tipped the bloody contents of the bucket into a smaller plastic container with a lid while her daughter lay shivering under a pink blanket.
‘I was just so relieved that the night was over and that we could go to the hospital to finish the process,’ Martha recalls.
A single-mother who lives in a poor and violent neighbourhood Martha had accompanied her daughter to the Termination of Pregnancy Clinic at Tygerberg Hospital, a teaching institution located in the city’s northern suburbs the previous day.
There the teenager had been given four Misoprostol tablets before being sent home with the caution that she would probably abort during the night. She was instructed to take two tablets orally and insert the other two into her vagina.
‘I thought they would keep Pamela and only send her home once the abortion was complete. So, I was quite surprised when they told us to take the tablets at home and return the next day with whatever she aborts during the night, in a container.
‘I was very worried as we do not have our own transport or a phone should something go wrong,’ said Martha.
After inspecting the contents of the container the following morning staff at the hospital informed Pamela that the debris did not contain ‘a foetus’ and that she would have to be admitted.
Pamela aborted later in the day after being given a second dose of Misoprostol.
‘The whole process was traumatic for us,’ added her mother.
Marie Adamo, head of hospital services in the Western Cape province confirms that this is standard procedure at Tygerberg: ‘Unfortunately I have no choice. Tygerberg have told me that they will stop doing terminations if I force them to do Misoprostol on site.’
There are only eight nurses and a few doctors in the province who are willing to do TOPs.
Across the country, methods and protocols vary considerably and more often than not women are forced to abort at home or at a health facility with very little or no supervision or assistance.
Six years on The Choice of Termination of Pregnancy Act was introduced in February 1997, one of the first significant health interventions introduced by the newly elected African National Congress, less than three years after the country’s first democratic elections.
The Act is based on certain fundamental human rights outlined in the Constitution of South Africa ‘ the right to equality, the right to freedom and security of the person, the right to healthcare, food, water and social security, the right to access to information, the right to freedom of religion, belief and opinion and the right to freedom of expression.
Professor Helen Rees, director of the Reproductive Health Research Unit at Chris Hani Baragwanath Hospital in Soweto, Johannesburg, outlines the principles underlying the Act’s implementation: Remove barriers, ensure maximum access to services, offer appropriate consent procedures, address negative attitudes of staff and communities, decentralise services, introduce appropriate technologies, train midwives and offer abortion counseling including contraception.
The Act stipulates that TOP services must be made available upon request to a woman during the first 12 weeks of pregnancy (first trimester) as well as from the 13th week up to and including the 20th (second trimester).
Second trimester is made available if the medical practitioner, after consultation with the pregnant woman, is of the opinion that the pregnancy would pose a risk to the woman’s physical, mental or social and economic well being or is a result of rape or incest. Second trimester terminations are also performed if there is a substantial risk to the foetus and the mother’s life.
Despite South Africa’s liberal TOP laws it is clear that there are few nurses and doctors willing to carry out the service and even fewer managers of institutions prepared to offer the support needed to make the service accessible and, in the case of clients such as Pamela, humane.
Researchers are unable confirm the number of doctors and nurses currently performing TOPs in the country’s nine provinces.
‘We tried to keep track of midwives and where they were deployed, but as the training unfolded it became impossible as many of them are not deployed in TOP after training – a management strategy to frustrate the service,’ according to head of the Reproductive Rights Alliance (RRA), Judi Merckel.
The RRA is a national alliance of organizations that promote, advance and ensure that all women can make a choice about their reproductive health and lives.
Merckel said that physicians served as back-up in hospitals for first trimesters while second trimester TOPs were mostly performed by Cuban doctors.
Staff morals vs. rights of the patient
Ipas director Kosi Xaba agrees that managers should be targeted for training.
‘They have all the power,’ said Xaba who also believes that the negative attitude is often as a result of ignorance, confusion and fear of the unknown.
‘A lot of work still needs to be done on people’s attitudes,’ she says.
Xaba lauds those health workers who do offer TOP services as ‘in a class of their own’.
‘A TOP provider is a different kind of government employee. One district manager told me that if all his staff had the commitment similar to the TOP providers he would have an amazing health service,’ says Xaba.
Last year Parliament’s National Portfolio Committee on Health and the RRA held oversight hearings into implementation of the Act. Elizabeth Serobe, a registered midwife from Gauteng, has been involved in TOP since its inception and was one of the presenters: ‘One reason I opted to render the service is because I saw women dying from back street abortions. One case that will always be in my mind is a young girl who had shot herself in the abdomen to get rid of the unwanted pregnancy. They came in with coat hangers hanging from their cervixes and lost their uteruses from sepsis.
‘I represent today these men and women who have dedicated their lives to save women from losing their lives and be able to exercise their reproductive right. I want to emphasise that we are saving lives,’ the diminutive nurse told members of parliament, stating that no level of intimidation or victimization would change her mind.
Second trimester TOPs
Another real challenge is the provision of second trimester TOPs. According Merckel, access to this service has varied from 34% of service provision in Year One to 23% in Year Five and represents 27% of overall TOP provision.
A survey done by the RRA identified a number of factors that contribute to the problems experienced with accessing second trimester TOPs. These include limited access to TOP services resulting in women being placed on long waiting lists which pushes them into their second trimesters; the widespread use of injectable contraceptives which can lead to irregular menses and an inability to detect early signs of pregnancy; the postponement of reporting a TOP for social reasons such as the changing status of the relationship with their sexual partner; an element of denial or real ignorance particularly when dealing with adolescents; and a significant number of women who are not aware of their rights under the Act.
Dutch physician Dr Marijke Alblas is one of only three doctors in the Western Cape who are willing to perform second trimester surgical abortions.
Unlike Tygerberg, staff at Groote Schuur, another teaching hospital in Cape Town, are willing to do second trimester TOPs, but only using dilation and evacuation, a costly procedure that requires women to occupy precious bed space.
Involved in reproductive health for the last 25 years, Alblas worked in the Netherlands before and after abortion was legalized in that country. She has trained doctors in Romania, Germany, and Belgium and, although illegally, also in Nicaragua, before heading for South Africa once TOPs were legalized.
‘I knew that to legalise it had been the easy part, implementing it would be difficult,’ says Alblas.
While Dutch funders sponsor Alblas’s salary, she currently works for the Department of Health in the Western Cape, one of only three doctors in the province who are prepared to do surgical abortions. Over the past 18 months she has travelled 65 000 kilometres to ensure that women who need the service can access it.
‘I helped to set up services and train people, but after three and half years I decided to simply do it (TOP) myself. By simply giving women a tablet (Misoprostol) they are forcing the women to do the TOP themselves. So I am now doing it because no one wants to do it,’ she says.
Merckel agrees that it is a problem that women are not properly assessed (gestational age) and are ill advised that taking Misoprostol will terminate a pregnancy successfully.
‘This remains an unsafe abortion and should be discouraged in the interest of women’s health. This practice does speak to a lack of access to services and will continue unless access to first trimester services and possibly medical abortions increases,’ says Merckel.
University of Cape Town researcher Dr Di Cooper conducted a feasibility study into medical abortions, surveying how women felt about the procedure.
A medical abortion involves the administration of RU486 (Mifepristone) in women who are less than 56 days pregnant with Misoprostol given 48 hours later.
In short, Cooper found a high level of acceptance among the service providers as well as clients. Presently, the cost of RU 486 is a hindrance. Operational research is currently underway in six sites.
Despite the hiccups, experts believe there has been a significant decrease in unsafe TOPs since legalisation.
In an earlier presentation to Parliament Dr Eddie Mhlanga, head of Maternal and Womens Health in the National Department of Health, confirmed that there had been a significant reduction in deaths and complication from unsafe abortions.
He reported that deaths had almost halved in 2000 (9,5% in 2000 compared to 16,5% in 1994). There had also been a significant increase in the use of manual vacuum aspiration for uterine evacuation and a reduction in the use of general anaesthesia.
Mhlanga lists one of the key challenges as the need to fast track the designation of facilities in the public sector. Current services are largely urban based and geographically inaccessible to many women who have to travel long distances.
Many non-governmental services are also financially inaccessible to women who are required to pay over R2 400 for a service that should be free. Long waiting periods are also resulting in many women progressing into second trimester, inflating the cost of the termination.
Mhlanga acknowledged that these challenges and obstacles led to the continued use of back-street abortionists and an increase in the number of second trimester abortions.
Mhlanga confirmed that some trained midwives and doctors had left for the private sector or had asked to be transferred out of the TOP service. This saw a collapse of TOP services in some facilities.
Xaba confirmed this, citing the example of Johannesburg Hospital where there is no doctor providing second trimester TOPs resulting in patients being ferried about 25km to Chris Hani Baragwanath Hospital.
Mhlanga said that TOP providers are also often overlooked for promotion, enjoy little support and face constant victimization and intimidation by managers and the community.
Why women still have illegal TOPs
A survey conducted by the Medical Research Council and Reproductive Health Research Unit attempted to explain why women are still opting for illegal abortions in Gauteng, a province that has the most extensive service provision in South Africa.
Of the 151 women interviewed at four hospitals, 46 had induced a termination. Researchers found that most of the women were older, less educated, had more children and younger children that those miscarrying.
Of those who had induced and who had not been deliberately seeking pregnancy, only 39% were using contraception (mostly oral).
‘I want a baby with all my heart. My boyfriend said I want to trick him. We fought until I gave up. He inserted a pencil under me and said I will thank him. He poked until I started bleeding. I have never been in so much pain,’ a one 33-year-old woman during her interview.
The study revealed that 22% of the women who had induced had been trying to fall pregnant while 66% of the women who had induced told the father of the pregnancy. These women reported that 31% of fathers had then instructed them to abort or were angry about the pregnancy.
Methods of induction included using ‘Dutch’ medicines (commercially available natural remedies), laxatives, Misoprostol, Ovral (a high-dose birth control pill), Quinine, traditional medicines or objects inserted into the cervix. The methods cost the women anything between R6 and R500.
Most turned to nurses, doctors, sangomas, priests and some had resorted to self-induced abortions.
A staggering 55% said they were unaware of the law and that this was their reason for not using a designated TOP facility.
This was followed by 17% who said they did make use of these facilities because they expected staff rudeness, 15% didn’t know a TOP facility, seven percent were afraid people would find out, four percent said the waiting list was too long and two percent were late.
Researchers concluded that there is a need for a public education campaign about abortion rights and that also provides specific information on who can access which services.
There is also a need for further promotion of emergency contraception while action also needs to be taken against staff who harassed abortion-seeking patients.
The study also highlighted the importance of training general practitioners and the need to encourage them to apply for registration to a designated facility as many women were seeking help at these facilities because of perceived better quality of care.
But resistance to the Act has also come on the legal front.
Over the six-year period the Act encountered two legal challenges; a constitutional case in 1997 to strike the Act in its entirety and an attack on minor service provisions in the Act in 2000. In the first instance the law was effectively defended.
The attack on minor service provision was based on the argument that there should be no circumstances in which a minor could consent to a termination of pregnancy without parental or court consent. The Christian Lawyers’ Association has since indefinitely postponed its arguments.
Six years down the line, a number of challenges continue to plague TOP services in South Africa:
- designated facilities that still refuse to provide TOPs;
- limited or no uptake of health care providers to undergo training leading to burn out and high stress levels among existing providers;
- a lack of access to second trimester terminations (preliminary research shows that second trimester services are often based on the presence of one medical practitioner, these practitioners are mainly not South African);
- conscientious objection is mainly among individuals as opposed to institutions;
- over-burdened health system within a context.
In retrospect there are a few things the country could or would have done differently.
Says Xaba: ‘We would have actively involved potential providers (midwives and doctors) from the start, so as to avoid situations where they say that they were not informed or consulted. We would also target the professional associations as they wield a lot of power.’
Xaba adds that it is crucial to create a public participation process avoiding a situation where communities perceive the Act as ‘a far away thing’.
Merckel agrees that health care providers should have been consulted during the drafting of the legislation.
‘They are at the cutting edge of service delivery and are required to function in disabling, unsupported environments, to render a service that is stigmatised,’ she said
* Names changed
E-mail Anso Thom
Anso Thom’s report was commissioned by the Reproductive Health & Gender Programme of the London Panos Institute on behalf of the international women’s health NGO, Ipas.